EDUCATIONAL WORKSHOPS 2009 CASE PRESENTATION TWO Orthopaedic graft infection Author: Savita Gossain,...

EDUCATIONAL WORKSHOPS 2009

CASE PRESENTATION TWOCASE PRESENTATION TWO

Orthopaedic graft infection

Author: Savita Gossain, Heart of England Foundation Trust

Sponsored through an unrestricted educational grant from Novartis Pharmaceutical Ltd to help support the

cost of developing and hosting this educational workshop series

Background

83 yr old FemalePast medical history: Hypertension, Gout, TIASevere osteoarthritis both hips; Left > RightOctober 2006Left THRProphylaxis: Cefuroxime x 3 dosesUneventful postoperative recoveryDischarged home 1 week later, wound healed


February 2007

Admitted with sepsis, Temp 40Cellulitis & collection over Left THR woundCRP 179, WCC 11.3Empirical iv vancomycin & ciprofloxacin

Wound aspirate: Group G StreptococcusChanged to iv Benzylpenicillin


February 2007

3 weeks later – no clinical improvement

Washout of hipPostoperative bleeding ++Iv Benzylpenicillin continuing


March 2007

Received 4 weeks iv Benzylpenicillin - changed to oralAntibiotics (Penicillin V)

Rash 3 days later, so changed to oral Erythromycin


March 2007

1 week after change to oral Erythromycin:

Further debridement & washout infected Left THRrequired, raised CRP

2 x swabs and 3 x tissue grew Enterococcus faecalis (Amp,Vanc sensitive)

IV Vancomycin commencedAuthor: Savita Gossain, Heart of England Foundation Trust

March & April 2007

Clinical improvement post-operatively although wounddischarge for 10 days.

Immunology Opinion:RAST test: IgE abs negative for Penicillin G and Penicillin

V.“Rash may have resulted from interaction between oral

Pen V and Allopurinol”.


April 2007

Clinically improved, keen for home

Received IV vancomycin for 3/52, discussion withMicrobiology re: cautious trial oral Amoxycillin to continuetreatment

Discharged home 13 April 2007 on po amoxycillin


End April 2007

Readmission with severe diarrhoea & vomiting, abdominalpainCDT positiveWCC 65CRP 349Surgical Review -> Conservative ManagementRx: Oral Vancomycin + iv Metronidazole then poVancomycin total 4/52.


June 2007Diarrhoea settled with antibiotic treatment of CDI and

rehydration etcOrthopaedic Review. No hip pain. Wound healed.

Mobilising, Discharged home 30/6/07.

QUESTION:Should Amoxycillin have been stopped?

(Had received 3/52 iv vancomycin and 2/52 oral amoxycillinafter last debridement and washout)


Nov 2007 – Dec 2008

Orthopaedic Outpatient Reviews. Pain in L hip and thigh. August 2008: CRP 84Xray: loosening acetabular cup in all 3 zones

Dec 2008:Xray: Loose femoral and acetabular componentAgreed for 2 Stage revision L THR


January 2009

Admission with pain in L THR and draining sinusCRP 105, WCC 7.1, ESR 117

1 week later:First stage of Revision L THR3/5 Tissue samples growing Enterococcus faecalis (Amp,Vanc Sensitive)IV Teicoplanin commenced 400mg. Low serum level.Changed to 600mg


March 2009

Received 4 weeks of iv teicoplaninWound discharge and CRP still raised (83)Superficial W/S grew Mixed coliformsDebridement & washout performed and cement spacerremovedTissue/fluid growing Proteus sp. (fully sens)Trimethoprim added to Teicoplanin


April 2009

Initial improvement but 4 weeks after startingtrimethoprim, CRP 65.

Further debridement & washout of hipTissue/Fluid samples: Proteus species as previouslyErtapenem commenced and Teicoplanin continued


June 2009

6/52 iv antibiotics, then 2/52 off antibiotics

2nd stage procedure with insertion new prosthesisAll tissue samples : No growthiv Ertapenem + teicoplaninPlan: 6/52 iv Abx (OPAT) and CRP monitoring


4 August 2009

Clinically wellMobilising with supportCRP 14IV antibiotics (OPAT) stopped after 8 weeks

Xrays of L Hip : next 2 slides


EDUCATIONAL WORKSHOPS 2009 CASE PRESENTATION TWO Orthopaedic graft infection Author: Savita Gossain,...

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